BACKGROUND AND OBJECTIVE: High-velocity low-amplitude thrust spinal manipulation (SM) is a recommended and commonly used manual therapy intervention in physiotherapy. Beliefs surrounding the safety and effectiveness of SM have challenged its use, and even advocated for its abandonment. Our study aimed to investigate the knowledge and beliefs surrounding SM by Italian physiotherapists compared with similar practitioners in other countries.METHODS: An online survey with 41 questions was adapted from previous surveys and was distributed via a mailing list of the Italian Physiotherapists Association (March 22-26, 2020). The questionnaire was divided into 4 sections to capture information on participant demographics, utilization, potential barriers, and knowledge about SM. Questions were differentiated between spinal regions. Attitudes towards different spinal regions, attributes associated with beliefs, and the influence of previous educational background were each evaluated.RESULTS: Of the 7398 registered physiotherapists, 575 (7.8%) completed the survey and were included for analysis. The majority of respondents perceived SM as safe and effective when applied to the thoracic (74.1%) and lumbar (72.2%) spines; whereas, a smaller proportion viewed SM to the upper cervical spine (56.8%) as safe and effective. Respondents reported they were less likely to provide and feel comfortable with upper cervical SM (respectively, 27.5% and 48.5%) compared to the thoracic (respectively, 52.2% and 74.8%) and lumbar spines (respectively, 46.3% and 74.3%). Most physiotherapists (70.4%) agreed they would perform additional screening prior to upper cervical SM compared to other spinal regions. Respondents who were aware of clinical prediction rules were more likely to report being comfortable with SM (OR 2.38-3.69) and to perceive it as safe (OR 1.75-3.12). Finally, physiotherapists without musculoskeletal specialization, especially those with a traditional manual therapy background, were more likely to perform additional screening prior to SM, use SM less frequently, report being less comfortable performing SM, and report upper cervical SM as less safe (p < 0.001).DISCUSSION: The beliefs and attitudes of physiotherapists surrounding the use of SM are significantly different when comparing the upper cervical spine to other spinal regions. An educational background in traditional manual therapy significantly influences beliefs and attitudes. We propose an updated framework on evidence-based SM.
BACKGROUND: Orthopaedic Manual Therapy (OMT) is a specialized area of physiotherapy for the management of neuromusculoskeletal conditions. Although rare, adverse events after OMT are reported in literature. In 2020, the International Framework for Examination of the Cervical Region for potential of vascular pathologies of the neck prior to OMT Intervention was presented.OBJECTIVE: To evaluate the knowledge and implementation status of OMT educational programmes regarding the 2020 International IFOMPT Cervical Framework.METHODS: An international survey with closed- and open-ended questions was conducted among all IFOMPT educational programmes using an online survey. Formal informed consent was requested at the beginning of the survey and all data were collected anonymously.RESULTS: Thirty-nine educational programmes filled in the survey. Twenty-four programmes (61.5%) had already implemented the new Framework. Four programmes (10.3%) answered that they will not implement the new Framework in their educational programme. Positional testing will be kept in about 54% of the programmes. Craniovertebral ligament testing will be kept in about 90% of the programmes. A considerable number of educational programmes still teach end range manipulations in the middle and lower cervical spine (33.3%) and upper cervical spine (25.5%).CONCLUSIONS: The dissemination and implementation of the International IFOMPT Cervical Framework among educational programmes has been successful. However, although positional testing and craniovertebral ligament testing are excluded from the Framework, most educational programmes will keep these tests in their curriculum, which raises some concern regarding the success and impact of international consensus frameworks.
Although there seems to be no causality between cervical spine (CS) manipulation and major adverse events (MAE), it remains important that manual therapists try to prevent every potential MAE. Although the validity of positional testing for vertebrobasilar insufficiency (VBI) has been questioned, recently, the use of these tests was recommended. However, based on the low sensitivity of the VBI tests, which may result in too many false-negative results, the VBI tests seem to be less valuable in pre-manipulative screening. Moreover, because the VBI tests are unable to consistently produce a decreased blood flow in the contralateral vertebral artery in (healthy people), the underlying mechanism of the test may not be a valid construct. There are numerous cases reporting MAE after a negative VBI test, indicating that the VBI tests do not have a role in assessing the risk of serious neurovascular pathology, such as cervical arterial dissection, the most frequently described MAE after CS manipulation. Symptoms of VBI can be identified in the patient interview and should be considered as red flags or warning signs and require further medical investigation. VBI tests are not able to predict MAE and seem not to have any added value to the patient interview with regard to detecting VBI or another vascular pathology. Furthermore, a negative VBI test can be wrongly interpreted as 'safe to manipulate'. Therefore, the use of VBI tests cannot be recommended and should be abandoned.
